Ann-Marie Pham Lindsey Marx Kimberly Ti l ley
NUTRITION CARE PROCESS
ON THE AGENDA…. • Get to know Karen Baker • Explore the Nutrition Care Process
(NCP) • Determine a diagnosis • Construct a PES statement • SOAP Notes
¡ Patient: Karen Maria Baker
¡ Age: 37 years old
¡ Height: 5’2” Weight: 170lbs. BMI: 31.1 ¡ Ethnicity: Hispanic and Caucasian
¡ Family: Husband (pastry chef) & 5 year old son
¡ Occupation: Customer Service Representative ¡ Physical activity: none
¡ Mother and aunt both have type II diabetes
¡ Enjoys pastries/sweets, bread, and soda ¡ Main Complaint: diagnosed with pre-diabetes
3 months ago, with a fasting blood sugar level of 115 mg/dl
KAREN BAKER
§ Nutrition Screening • Obtain crucial information to determine who is at
nutritional risk and needs to enter the nutrition care process
§ Data Collection
• Subjective: from patient, family member, or health care worker (RD or practitioner)
• Objective: from medical records
PRE-NUTRITION CARE PROCESS
¡ A - NUTRITION ASSESSMENT: § Nutrition-related history, biochemical data, anthropometric
measurements, client history
¡ D - NUTRITION DIAGNOSIS: § Problem, Etiology, Signs, and Symptoms (PES Statement)
¡ I - NUTRITION INTERVENTION: § Plan and implement solution to diagnosis
¡ M - NUTRITION MONITORING and ¡ E - NUTRITION EVALUATION
§ Assess progress made to achieve goals
NUTRITION CARE PROCESS
ASSESSMENT
• § Step 1: Nutrition Assessment • Groundwork of the Nutrition Care Process • Definition: process of obtaining, verifying, and interpreting
data necessary to make decisions about the type and source of nutrition related problem
§ Domains of Nutrition Assessment • Food/Nutrition-Related History (FH) • Anthropometric Data (AD) • Biochemical Data, Medical Tests, Procedures (BD) • Nutrition-Focused Physical Findings (PD) • Client History (CH)
¡ Food/Nutrition-Related History (FH) § Food & nutrient intake § Nutrition and health awareness and management § Physical activity § Food availability
¡ Anthropometric Data (AD) § Height, Weight, % Usual Body Weight, Weight change
¡ Biochemical Lab/Data, Medical Tests, Procedures (BD) § Ex: albumin, blood glucose, HbA1c, LDL, etc.
¡ Nutrition-Focused Physical Findings (PD) § Oral health, physical appearance, temporal wasting
¡ Client History (CH) § Gender, age education, nutrition-related/medical history
ASSESSMENT
NUTRITION DIAGNOSIS
§ Step 2: Nutrition Diagnosis • 1. Identify the problem (singularly)
• 2. Determine cause/risk factors associated with problem
• 3. Identify the characteristic symptoms the patient is presenting with
• 4. Documentation (throughout NCP)
§ Nutrition Diagnosis • Diagnosis are formatted as “PES
Statements” • Utilizing the International
Dietetics & Nutrition Terminology (IDNT) reference manual ensures that standardized terminology is used.
• Standardized terminology = é understanding of patient information between different providers
PES STATEMENT
§ Problem: Requires use of exact wording and coding (standardized language) • Pinpoint singular issue (one problem per PES) • Coding allows for increased efficiency in financial
compensation/billing
§ Etiology: Explains why the problem exists • Exact wording from IDNT reference manual
NOT required § Signs/symptoms: Proves the “why”
• Measurable data used to confirm and prove
PES OUTLINE
§ P: What is wrong? § Zero in on one problem
• As related to…
§ E: Why is this occurring? § Causation
• As evidenced by…
§ S: How do we know? § What measurable data do we
have to prove this?
DIAGNOSIS
§ Plug in the information: P: Excessive carbohydrate intake
(NI-5.8.2) E: Unregulated blood glucose levels
and lack of nutrition knowledge S: Reported binge eating,
weight gain and HgA1c levels of 8.6%
PES FOR KAREN BAKER
Excessive carbohydrate intake (NI-5.8.2) as related to
unregulated blood glucose levels and lack of nutrition
knowledge as evidenced reported binge eating, weight
gain and HgA1c levels of 8.6%.
INTERVENTION
¡ STEP 3: NUTRITION INTERVENTION ¡ Outline nutrition intervention (End goal) § Determine goals, plan of action to meet
them and expected outcomes • Steps that aim to solve/improve diagnosis • Must be individualized to specific patient to be
successful
§ If more than one PES statement applies, PRIORITIZE • Implement intervention • Document (throughout NCP)
INTERVENTION
¡ The intervention must considers a patient’s individual dietary habits, lifestyle and other personal goals
o Example: vegetarian, who they live with, income, etc…
o Goals must be specific & measureable o Goals should be adjusted as clinical
picture changes
LONG TERM DIETARY INTERVENTION
¡ Determine the individuals readiness for change § Stages of Change:
§ Pre-contemplation § Contemplation § Preparation § Action § Maintenance
¡ Emphasize what to eat, rather than what not to eat § Set realistic goals. § Nutrition education.
MONITORING AND EVALUATION ¡ STEP 4: NUTRITON MONITORING AND
EVAULATION § Determine whether the patient/client is achieving
their goals and desired outcomes. § May be necessary to update assessment data or
diagnosis. § Monitor, measure, evaluate
MONITORING AND EVALUATION
¡ Monitor § Check patient/client’s understanding and compliance with nutrition
intervention § Determine if intervention is being implemented § Gather information that may explain lack of adherence
¡ Measure § Collect data on appropriate nutrition care indicators
§ Example: weight, HgA1C
¡ Evaluate § Compare monitoring data with nutrition goals
or reference standard to assess progress § Evaluate how interventions affect patient’s overall
health outcomes
¡ Characteristics of monitoring and evaluation: • Measurable
• Related to PES statement
• Communicates expected outcomes
• Patient-centered
• Individualized
MONITORING AND EVALUATION
MONITOR AND EVALUATE FOR KAREN BAKER
§ What do we need to monitor and evaluate for Karen Baker? • Adherence to carbohydrate counting • Challenges that prevent her from making changes
§ Examples: husband brings home pastries, lack of cooking skills
• Measure weight, HgA1C • Evaluate and reassess her goals
SOAP NOTES FOR KAREN BAKER
§ Assessment: • Nutrition diagnosis or interpretation of
the patient's nutrition problems § Plan:
• An outline of interventions necessary to treat each nutrition problem
§ Subjective: • Patient information or data collected from the
patient or caregiver § Objective:
• Empirical information, medical staff observations, age, gender etc.
Thank you! Any Questions?